Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review

Introduction Migrant, internally displaced, asylum seeking and refugee women experience ongoing risks of having their reproductive healthcare rights violated. This ever-increasing population also has limited access to sexual and reproductive health services. We conducted a scoping review to identify the barriers and facilitating factors when accessing sexual and reproductive health services for this specific population. Methods We searched the grey literature and queried eight bibliographic databases (Embase, Medline, Cinahl, Scopus, Science Direct, Web of Science, Hinari, and Cochrane Library) to extract articles published between January, 2000, and October, 2021. The extracted data were organized in a framework adapted from Peters et al. and then categorized as facilitators or barriers. We followed the Arksey and O’Malley framework and wrote the report according to the PRISMA-Scr recommendations. Results The search identified 4,722 records of which forty-two (42) met eligibility criteria and were retained for analysis. Ten (10) groups of factors facilitating and/or limiting access to sexual and reproductive health care emerged from the synthesis of the retained articles. The main barriers were lack of knowledge about services, cultural unacceptability of services, financial inaccessibility, and language barriers between patients and healthcare providers. Facilitators included mobile applications for translation and telehealth consultations, patients having a wide availability of information sources, the availability health promotion representatives, and healthcare providers being trained in cultural sensitivity, communication and person-centered care. Conclusion Ensuring the sexual and reproductive rights of migrant, internally displaced, asylum-seeking and refugee women requires that policymakers and health authorities develop intervention strategies based on barriers and facilitators identified in this scoping review. Therefore, considering their mental health in future studies would enable a better understanding of the barriers and facilitators of access to sexual and reproductive health services.


Introduction
Migrant, internally displaced, asylum seeking and refugee women represent a vulnerable group whose number is constantly growing.According to the Office of the United Nations High Commissioner for Refugees (UNHCR), the number of migrants, internally displaced persons (IDPs), asylum seekers and refugees worldwide reached 82 million in 2020, a 28 per cent increase from 2015 [1].These women live in precarious conditions that increase the probability of their reproductive healthcare rights will be violated.For example, both women and adolescent girls living in internally displaced persons (IDPs) and refugees camps have increased risk of contracting sexually transmitted infections, having unwanted pregnancies and abortions [2,3].Despite these increased risks, healthcare centers in host localities do not always take these concerns into account, resulting in women having limited access to appropriate sexual and reproductive health (SRH) services [4,5].SRH services include prenatal care, childbirth care, newborn care, family planning, safe abortion, and the management of sexually transmitted infections (STI) and human immunodeficiency virus (HIV) [6].
Access to SRH services is a fundamental human right that was highlighted at the 1994 International Conference on Population and Development (ICPD) and reinforced in the priorities set out in the 2030 Agenda of the Sustainable Development Goals [7].In these commitments to healthcare, legislators and public healthcare authorities have been mandated to ensure that all individuals, without discrimination, have universal access to SRH services.Given the vulnerability of migrants, IDPs, asylum seekers and refugees, specific evidence-based measures are needed to promote their access to SRH services.For this purpose, it is important to identify barriers and facilitators of access to SRH care for migrant, internally displaced, asylum seeking and refugee women.The studies that have examined this issue provided insights into the influence of communication and socio-cultural factors as well as factors related to the quality of services that facilitate or limit access to SRH services for migrant, internally displaced, asylum seeking and refugee women.Two review articles on barriers and facilitators of access to SRH care specifically focused on adolescent girls and young women [2,8], while another concerned adult women aged 18 to 64 years but was limited to preventive SRH care, excluding maternity care, obstetric care and HIV/STI prevention [9].Therefore, much remains unknown about barriers and facilitators of access to other relevant SRH services (including prenatal care, childbirth, postnatal care, HIV/STI) for migrant, internally displaced, asylum seeking and refugee women.
This study aims to provide evidence-based data that may serve to improve the access to and use of SRH services for migrant, internally displaced, asylum seeking and refugee women.This review concerns women of all age, from early adolescents to older adults.It answers the following question: according to the scientific literature, what are the barriers and facilitators of access of sexual and reproductive health care for migrant, internally displaced, asylum seeking and refugee women?

Methods
This study is a scoping review of the scientific literature based on the framework of Arksey & O'Malley [10].The findings are reported as per the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRIS-MA-Scr) [11].The reviews were registered within Research Registry (https://www.researchregistry.com/register-now#registryofsystematicreviewsmeta-analyses/,reviewregistry1394).

Eligibility criteria
Inclusion criteria were based on the population to be included, the risk factors to be considered, the design of the studies, the geographic scope, and the timeframe.For inclusion, selected articles must: 1. Be published in French or English, the working languages of the research team; 2. Be published between January 1 st , 2000 and October 15 th , 2021.The year 2000 was the deadline to ensure universal access to healthcare [12], including for migrants, internally displaced persons, asylum seekers or refugees.We thus considered this year as the starting point of our study period; 3. Include data on females who were 12 years old or older.We considered this age group because an earlier study showed that some girls are sexually active by the age of 12 [13]; 4. Describe migrant, internally displaced, asylum seeking or refugee women; 5. Focus on access to SRH, including prenatal consultations, childbirth, postnatal care, immunization, healthy infant care, family planning, and management of sexually transmitted infections; 6. Focus on barriers and facilitators; 7. Editorials, commentaries, methodological guides, manuals, and review articles (including systematic reviews) were excluded.

Data sources and search strategy
We developed a search strategy using keywords based on the eligibility criteria.The keywords used included both free and controlled vocabulary.These keywords refer to the study population (refugee or "asylum seeker" or displaced or migrant), the type of services ("healthcare accessibility") and the focus of the study (barriers or obstacles or "facilitating factors").Spelling variants and synonyms of the keywords were also considered in the construction of the search syntax.We queried eight databases: Embase, Medline, Cinahl, Scopus, Science Direct, Web of Science, Hinari, and Cochrane Library.We also searched grey literature on Open Grey database, on the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) website and on the UNCHR website.The complete search syntax applied in each database is presented in S1 Appendix.

Selection of articles
The selection of articles was done in several steps.In the first step, the search strategies were applied to the databases to retrieve the references of the articles whose title, abstract or keywords contained the words composing the search equations.Subsequently, the records retrieved were imported into an EndNote library where duplicates were detected and removed.
Articles were then imported into Rayyan for the selection of articles according to eligibility criteria.Authors PMS, SD and ETN reviewed the titles and abstracts according to the process described in Fig 1 .In the case of disagreement, authors YO and SG independently reviewed titles and abstracts and their decision was used to resolve the conflict.The full texts of the selected articles were then uploaded into Rayyan and read by four co-investigators (SPM, SG, NS and AG) to eliminate those that did not meet eligibility criteria.In the event of a discrepancy, a co-investigator (IB or SR) reviewed the given article to settle the conflict.

Data extraction
Articles were organized according to the geographical area where the study was conducted.Then, using a seven-item data extraction grid, we extracted the data.The seven items included: references, country of study, study population, type of study, type of service, facilitating factors and barriers.To ensure that the extraction grid was understood and used in a uniform manner, data extracted from the first five articles was done as a team during two working meetings.
During this group extraction phase, no amendments were made to the form.Subsequently, the data from the remaining articles were extracted by authors PMS SD, MG and ETN.

Data analysis
The extracted factors were organized according to Peters et al. framework and adapted for an analysis of access to healthcare in the context of instability [14].The framework centers on four main factors of access, notably: availability, geographical accessibility, financial accessibility, and acceptability.In addition, our review identified six other relevant factors, including: patient-provider communication, client knowledge, decision-making autonomy, stigma/discrimination, and administrative factors.Each factor was considered in the model and categorized as a facilitator or barrier.Finally, the frequency of the identified factors is reported.

Results
Fig 1 shows the record selection process.A total of 4,124 records were identified from the eight bibliographic databases.Upon importing the references into EndNote software, 564 duplicates were automatically deleted, leaving 3,650 records.The remaining references were imported into the Rayyan platform.A review of these titles and abstracts resulted in the selection of 155 references whose full texts were reviewed.In the end, 42 articles were retained for data extraction.In addition, 508 grey literature references were identified.However, none met the eligibility criteria.

Characteristics of the retained articles
The characteristics of the 42 selected articles are presented in Table 1.The studies spanned 30 countries.The Asian continent was the most represented with 16 articles describing studies in 12 countries, followed by the African continent (13 studies) which were mainly about Uganda (n = 5), Kenya (n = 3) and Ghana (n = 3).Methodologically, 29 studies were qualitative, ten studies used a mixed methods approach, and three were quantitative.In addition, 15 of the 42 studies focused on SRH in general and described "reproductive healthcare services" or "maternity services".The remaining 27 studies focused on one or more specific services, including primarily prenatal healthcare, contraceptive/family planning, and childbirth services.Women receiving healthcare services were interviewed in all 42 studies.In addition, healthcare providers were interviewed in seven of the 42 studies.Two studies included key informants [15,16].With respect to the profile of the study population, 24 of 42 studies focused exclusively on immigrant women, ten on refugee women, and four on internally displaced persons.Two studies included both refugees and immigrants [17,18], one study included asylum seekers [19], and one study included refugees and internally displaced persons [20].

Barriers and facilitators of access to sexual and reproductive health services
Fig 2 presents all the factors identified as facilitating or constraining the use of SRH by migrant, internally displaced, asylum seeking and refugee women.Factors were grouped into ten groups: geographic accessibility of services, availability of services, quality of services, communication, financial accessibility of services, knowledge of services by beneficiaries, cultural accessibility of services, stigma/discrimination, women's decision-making autonomy and administrative factors.

Geographic accessibility of services
Six of the 42 studies described geographic accessibility to healthcare services that impede access to SRH services for migrant, internally displaced, asylum seeking and refugee women.These include the distance from healthcare centers [22,27,48,56] and lack of transportation [27,45,54].On the other hand, two studies reported that the use of mobile healthcare teams in migrant welcome sites as a factor that improved the use of SRH services [45,47].

Quality of services
Eleven of 42 studies described barriers inherent in the quality of SRH services that were barriers to their use by migrant, internally displaced, asylum seeking and refugee women.Five articles noted a lack of confidentiality when receiving care [30,31,36,41,47], which was sometimes related to inadequate facilities or the use of a patient's relatives as interpreters [36].
Feeling unwelcome was cited in five studies [16,23,28,31,56].Two studies cited the patient's inability to choose which gender of providers they could see as a barrier to using services [39,43].The high workload of healthcare providers was identified as a barrier in three articles [16,27,31].
Five studies showed that communicating in many diverse languages promotes access to SRH services for migrant, internally displaced, asylum seeking and refugee women [20,33,38,39,47].Similarly, three studies described how using a mobile app on smartphones to disseminate information about SRH services supports their use [37,49,50].As well, providing a professional translator [27,40,47], using a family member as an interpreter [53,57], and diversifying information sources [9] can break down communication barriers and thus promote the use of services.

Financial accessibility
Seventeen studies reported financial factors as barriers to SRH services.These were primarily women's low purchasing power [16,22,26,29,30,[43][44][45]51], and the high cost of services [22-24, 33, 38, 40-42, 44, 48, 56, 57].Financial barriers are particularly important in some settings where the cost of services is higher for migrant women than for native women [21].This is also the issue when migrant women, unlike local women, do not have access to social security services [51].
Practices that have been developed to increase migrant women's knowledge and thus promote the use of reproductive health services were highlighted in two studies.This included the provision of health promotion representatives to improve migrant women's knowledge about the availability of SRH services and thus encourage their use [38,40].

Cultural acceptability of services
Fifteen studies identified sociocultural considerations that conflict with the requirement for reproductive health services.Four studies found that some migrant, internally displaced, asylum seeking and refugee women have pro-natalist beliefs, which is conflicts with inherent need for contraceptive services [18,20,33,51].Nine articles describe the cultural imperative of sexual abstinence for unmarried women and for those whose husbands are away from home.This prevents women from using family planning or receiving STI or prenatal care [15,17,18,20,27,28,30,42,57].In the same vein, one study found that the social imperative of virginity inhibited unmarried girls from obtaining cervical cancer screening, HPV vaccination, or family planning services [18].In addition, three articles showed that the use of traditional medicine or other alternatives (e.g.self-medication) in the place of modern reproductive healthcare reduced the use of SRH services [22,25,36].
In one study, the fact that healthcare services did not allow an attendant for women in labor limited the use of labor and delivery services [54].Similarly, the presence of religious symbols that are incompatible with migrant women's beliefs hinder the use of healthcare centers [47].Finally, women reported not accessing services due to experiencing feelings of shame when they were required to be examined naked during gynecological examinations, a necessity for prenatal consultations, STI management and family planning services [17].
In addition to sociocultural barriers, similar facilitating factors were reported.For example, six studies reported that programming of services by community groups [32], developing a partnership with community leaders [33,47], and having home healthcare visits [27,45] made it possible to remove cultural barriers to the use of SRH services.Similarly, a positive effect was seen in two studies when healthcare providers received training on person-centered care [31,32].Finally, four studies reported positive effects from the training of healthcare providers on cultural sensitivity and cultural communication [33,38,39,47].

Stigma/Discrimination
Five studies describe that the stigma of being a migrant, internally displaced person (IDP), asylum seeker or refugee was a barrier to the use of SRH services [17,27,32,43,49].Feelings of discrimination were also reported in seven studies [21,27,28,31,38,43,54].Finally, women were not motivated to seek preventive care as they considered it relatively less important in comparison to the multitude of other problems they faced [46].

Autonomy in decision-making
Insufficient autonomy in decision-making was identified as a barrier to the use of SRH services.This reflects the low decision-making power of women, the effect of which was identified in nine studies [15,16,23,25,33,35,43,55,57].Barriers related to decision-making autonomy are exacerbated by spouses' low level of education [51] and lack of involvement in reproductive healthcare issues [57].

Administrative factors
Four studies reported that the lack of documents required for healthcare access limits access to reproductive health services for migrant, internally displaced, asylum seeking and refugee women [21,43,44,48].

Discussion
This review provides an up-to-date synthesis of knowledge on the barriers and facilitating factors related to the use of SRH services by migrant, internally displaced, asylum seeking and refugee women.It thus offers insight into how to support the management of this vulnerable population regarding an important part of their healthcare needs.This synthesis discusses the geography of the studies, the populations studied, and the factors identified.
Geographically, Asia was the most represented continent, providing more than one-third of the articles reviewed (16 of 42).Studies based in countries from the African continent (n = 13), Europe (n = 10) and North America (n = 4) provided the remaining literature.Despite receiving important numbers of migrants, North America was relatively underrepresented in the literature retrieved.In 2020, the International Organization for Migration estimated that North America was the third region in the world -behind Europe and Asia-in terms of absolute numbers and proportions of migrants [1].As well, few studies focused on West African countries.However, ongoing terrorism in this part of the world provokes massive internal displacements of populations, particularly in Nigeria, Mali, Niger, and Burkina Faso [58].Future studies on access to SRH services should focus on the needs of women in West Africa.
Within the populations studied, internally displaced persons and refugees were relatively poorly represented (only 17 of 42 articles selected for this scoping review).However, the circumstances of their displacement, which is most often brutal, make them a particularly vulnerable sub-population that deserves to be better studied.Indeed, violent conflicts that lead to their rapid departure force refugees to abandon their belongings and property.Subsequently, most live in temporary settlement sites or camps, and they are at a particularly high risk of having their SRH rights violated [59].Further research on access to reproductive healthcare services should focus exclusively on these forcibly displaced people.
The factors identified as barriers and facilitators were grouped into ten dimensions.These are geographic accessibility, availability of services, quality of services, communication, affordability, knowledge of services, cultural acceptability, stigma/discrimination, decision-making autonomy, and administrative factors.Overall, no factor emerged that was exclusively found to apply to migrants or IDPs or asylum-seekers or refugee women.In the studies that only focused on internally displaced women, language issues were not reported.This is understandable considering they are still within their country of origin.
With regards to the frequency of factors identified, lack of knowledge about services (n = 20), cultural unacceptability of services (n = 18), financial inaccessibility (n = 17), and language barriers (n = 17) were the main barriers to accessing to SRH services by migrant, internally displaced, asylum seeking and refugee women.Actions to improve access for this specific population should focus on these factors.
The most commonly faced barrier (from a frequency perspective) to accessing SRH services was insufficient knowledge about the services.These studies show that migrant, internally displaced, asylum seeking and refugee women are not aware of the services that are provided, nor are they aware when the healthcare service or clinics are open.These findings are in line with a scoping review that reported lack of knowledge and information was the main barrier to the use of reproductive health services for refugee girls [8].The convergence of these results shows that among migrant, internally displaced, asylum seeking and refugee women, the lack of knowledge and information concerns not only girls but all ages of women.Displaced women undergo changes to their healthcare system, and thus, have lost the experiential capital they had accumulated in their land of origin.Language barriers contribute to this lack of knowledge about healthcare services.However, it emerged from the literature that the use of mobile applications on smartphones [37,49,50], having a variety of information sources [39], and the provision of health promotion representatives [38,40] can break down language barriers and improve knowledge of migrant, internally displaced, asylum seeking and refugee women about SRH services.
This review also highlights cultural concerns that influence access to SRH services for migrant, internally displaced, asylum seeking and refugee women.For example, pro-natalist beliefs and traditions may not allow women to use family planning services.The same is true for social rejection of premarital sex and the social stigma of sex outside marriage.These longacquired cultural beliefs are still very much alive in the migrant, internally displaced, asylum seeking and refugee women even when they move to and live in their host sites.So, healthcare providers for migrant, internally displaced, asylum seeking and refugee women must be trained in cultural sensitivity and cultural communication [33,38,39,47], and in person-centered care [31,32].
Although less frequently described, stigma and discrimination (n = 13) along with low decision-making autonomy (n = 9), are barriers that merit attention.To bring about significant improvement in access for migrant, internally displaced, asylum seeking and refugee women requires that women have the autonomy to make decisions.This is especially important because social stigma regarding reproductive health issues is prevalent in these communities.
Given the precariousness of their living conditions and the violence that has sometimes surrounded their displacement, the extent of mental health disorders could be particularly significant among migrant, internally displaced, asylum seeking and refugee women.These mental health disorders constitute a potential limit to access to SRH services, which has been little investigated.Taking mental health into account in future studies would enable a more complete understanding of the barriers to accessing SRH services for migrant, internally displaced, asylum seeking and refugee women.

Strengths and weaknesses
A major strength of this review is that it has allowed for the development of a framework for analyzing the drivers and barriers to access to sexual and reproductive health services.This framework, an adaptation of Peters et al. [14], considers the lived experiences of the issues faced by migrant, internally displaced, asylum seeking and refugee women regarding sexual and reproductive healthcare access.It can be used as a framework for analyzing factors influencing the use of reproductive health services for these populations in future studies.
Another strength of this review is that we consulted a large number of databases (n = 8), which allowed for the retrieval and review of many articles.Similarly, the broad geographic scope allowed for the investigation of this issue in parts of the world that deserve further study.This synthesis provides an almost complete picture of the facilitating factors and barriers to the use of reproductive health services by migrant, internally displaced, asylum seeking and refugee women.
The main limitation of this study is the heterogeneity of the study population.Indeed, our study population includes people who were forced into displacement (IDPs, asylum seekers and refugees) and ordinary migrants whose displacement was planned.Thus, the challenges in accessing reproductive healthcare services may be different for each.Pooling these two subpopulations complicates the interpretation of the results.Future synthesis studies should focus on a more homogeneous population.

Conclusion
Promoting access to sexual and reproductive health services, a fundamental human right, requires a good knowledge of the facilitating factors and obstacles to their access to such services.This scoping review provided an overview of the current literature on the subject.We identified ten groups of factors that promote or restrict access to reproductive healthcare services for migrant, internally displaced, asylum seeking and refugee women.Based on this evidence, we have built a conceptual framework that can be used for a holistic analysis of the barriers and facilitators of access to SRH services for migrant, internally displaced, asylum seeking and refugee women.Policymakers and health authorities must develop intervention strategies based on these factors to protect the reproductive healthcare rights of this specific population.The critical analysis of the literature also highlighted the need to take into account the mental health of migrant, internally displaced, asylum seeking and refugee women which, to date, has received little attention.

Fig 2 .
Fig 2. Conceptual framework of facilitating factors and barriers to access to reproductive health services by migrant, internally displaced, asylum seeking and refugee women.https://doi.org/10.1371/journal.pone.0291486.g002